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Gross Anatomy of the PERICARDIUM and HEART M1 Gross and Developmental Anatomy 8:00 AM, November 7, 2007 Dr. Milton M. Sholley Professor of Anatomy and Neurobiology 1 Jeff Dupree Sanger Hall 9-057 828-9536 E-mail: [email protected] 2 Left atrium Right auricle Right auricle Right ventricle Right ventricle Left ventricle Opened Chambers of the Human Heart 3 Mediastinum 4 Subdivisions of the Mediastinum (Mid-sagittal plane drawing from Textbook of Anatomy by W. Henry Hollinshead) 5 II. Pericardial sac Fibrous pericardium (inferiorly fuses to central region of diaphragm) Phrenic nerve: from cervical spinal nerves (C3-C5) Pericardiacophrenic artery and vein 6 Note the opened Pericardial Sac The pericardial sac is the space between the parietal and visceral layers of the serous pericardium. The sac normally contains only a thin layer of serous fluid, but inflammation of the sac (pericarditis) can cause a large increase in the volume of fluid. The visceral layer of pericardium (or epicardium) tightly adheres to the surface of the heart The fibrous layer of pericardium is thick and makes the pericardial sac tough and inflexible The parietal layer of pericardium tightly adheres to the inside of the fibrous pericardium Grant’s Atlas, 12th Ed.,7 Fig. 1.21, p. 25 Cut edge of fused fibrous (outside) + parietal (inside) layers of pericardium Fibrous pericardium Pericardial sac Parietal layer Serous pericardium Visceral layer Pericardial sac Diagrammatic Coronal Section Grant’s Atlas, 11th Ed., 8 Fig. 1.57B, p. 63 Superior View of Diaphragm The fibrous pericardium is fused to the superior surface of the diaphragm. Thus, the heart moves up and down with the diaphragm during respiration. Pericardial sac Inferior vena cava R L Esophagus Aorta Grant’s Atlas, 12th Ed., 9 Fig. 1.70A, p. 73 Layers of the Heart Wall (page 266) Fibrous pericardium: (inferiorly fuses to central region of diaphragm) Epicardium: Visceral pericardium Fat and blood vessels Myocardium: heart muscle Endocardium: innermost endothelial layer) 10 II. Pericardial Sinuses (page 266) Transverse pericardial sinus Oblique pericardial sinus 11 Transverse Pericardial Sinus Transverse pericardial sinus: Between pericardial attachments to pulmonary veins and SVC and the aorta and pulmonary trunk 12 Oblique and Transverse Pericardial Sinuses Pulmonary trunk Superior vena cava Transverse pericardial sinus Right superior pulmonary vein Left superior pulmonary vein Right inferior pulmonary vein Left inferior pulmonary vein The base of the heart sits here, forming the opposite (anterior) wall of the oblique pericardial sinus. The line of junction between the parietal and visceral layers of serous pericardium surrounds the six great veins and creates a cul-desac known as the oblique pericardial sinus. Inferior vena cava Posterior wall of opened pericardial sac – heart removed Grant’s Atlas, 12th Ed., 13 Fig. 1.44B, p. 51 The Esophagus and Thoracic Aorta lie behind the Oblique Pericardial Sinus Esophagus Grant’s Atlas, 12th Ed., Fig. 1.44B, p. 51 Aorta 14 The Esophagus and Thoracic Aorta lie behind the Oblique Pericardial Sinus Esophagus Grant’s Atlas, 12th Ed., Fig. 1.44B, p. 51 Aorta 15 16 17 AA = Ascending aorta AR = Aortic arch DA = Descending aorta BT = Brachiocephalic trunk RS = Right subclavian a. RC = Right common carotid a. LC = Left common carotid a. LS = Left subclavian a. R C L C RS BT LS AR AA DA 18 III. External form of the Heart Coronary (or atrioventricular) sulcus Anterior interventricular sulcus Sternocostal surface Anterior view Base Diaphragmatic surface Posterior interventricular sulcus Posterior view 19 Sulci of the Heart 20 IV. Blood Supply of the Heart Right coronary a. SA nodal branch Conus Right marginal AV nodal branch Posterior interventricular Left coronary a. Anterior interventricular Diagonal branches Circumflex Posterior ventricular Left marginal 21 Coronary Arteries SA nodal branch Left coronary artery (main stem) Circumflex branch Right coronary artery Left anterior descending branch (LAD) Left marginal branch Diagonal branch of LAD Conus branch Note: LAD is also called the anterior Interventricular branch Right marginal branch Anterior view Grant’s Atlas, 12th Ed., 22 Fig. 1.45A, p. 52 Coronary Arteries Note: The crux of the heart is the area of junction of the atrioventricular and posterior interventricular sulci. If the right coronary artery gives off the posterior Interventricular (as here) the pattern is “right dominant”. If the circumflex branch of the left coronary reaches the crux and gives off the posterior interventricular the pattern is”left dominant”. About 60% of hearts are “right dominant”. AV nodal branch Circumflex branch Crux of heart Posterior interventricular (posterior descending) branch Posterior view Grant’s Atlas, 12th Ed., 23 Fig. 1.45B, p. 52 Sinuatrial nodal a. Left coronary a. Circumflex a. Right Coronary a. Marginal a. Anterior Interventricular a. Right marginlal a. 24 Sinuatrial nodal a. Circumflex a. Left marginal a. Posterior ventricular a. Right Coronary a. Right marginal a. Posterior interventricular a. 25 Right dominant coronary circulation (what we studied just studied) ~60% of cases Left dominant coronary circulation ~40% of cases 26 Anomalous Origins of Coronary Arteries Single coronary artery (bad news if it becomes blocked) Circumflex artery arising from right coronary sinus 27 LIMA Graft Provides an Artery to Artery Bypass around a Blocked LAD LIMA LAD Fibrous pericardium The left internal mammary artery (LIMA) lies very close (just outside the pericardial sac) to the left anterior descending artery (LAD). It can be diverted and anastomosed to the LAD to bypass a blockage in 28 this important arterial supply to the left ventricle and interventrticular septum. Cardiac veins Great cardiac Middle cardiac Small cardiac Anterior cardiac Least cardiac 29 Cardiac veins Anterior cardiac veins Great cardiac vein Oblique vein of left atrium Middle cardiac vein Coronary sinus Small cardiac vein Anterior view Grant’s Atlas, 12th Ed., 30 Fig. 1.46A, p. 53 Cardiac veins Oblique vein of left atrium Great cardiac vein Coronary sinus Left marginal vein Middle cardiac vein Left posterior ventricular vein Small cardiac vein Grant’s Atlas, 12th Ed., 31 Fig. 1.46D, p. 53 Posterior view Left atrium Right auricle Right auricle Right ventricle Right ventricle Left ventricle Opened Chambers of the Human Heart 32 33 Right Atrium Opened Pectinate muscles (rough part of wall) Fossa ovalis SVC Crista terminalis Orifice of coronary sinus Valve of IVC IVC Right atrioventricular orifice Grant’s Atlas, 12th Ed., 34 Figs. 1.49 A&B, p. 56 Right Ventricle Opened Orifice of pulmonary valve Septal papillary muscles Conus arteriosus Septal cusp Chordae tendineae Posterior papillary muscle Moderator band Anterior cusp Anterior papillary muscle Grant’s Atlas, 12th Ed., 35 Figs. 1.50 A, p. 57 Posterior cusp Left auricle Left superior pulmonary v. Valve of foramen ovale Right pulmonary v. 36 Left Ventricle Opened Posterior sinus of aortic valve Posterior (non-coronary) cusp of aortic valve Orifice of right coronary artery Orifice of left coronary artery Right aortic sinus Left aortic sinus Right cusp of aortic valve Left cusp of aortic valve Membranous interventricular septum Anterior cusp of mitral valve Chordae tendineae Posterior cusp of mitral valve Anterior papillary muscle Trabeculae carneae Posterior papillary muscle Grant’s Atlas, 12th Ed., 37 Figs. 1.52A, p. 59 Detail of the Aortic Semilunar Valve Orifice of the right coronary artery Lunule Nodule Nodules meet when the valve cusps close Orifice of the left coronary artery Aortic sinus RC PC LC Orifice of a coronary artery Right coronary artery Left coronary artery 38 Aortic and Pulmonary Semilunar Valves Aortic valve P L R L R A Pulmonary valve Grant’s Atlas, 12th Ed., 39 Figs. 1.53 & 1.54C, p. 60 Superior view Cardiac Conduction System Superior vena cava Location of SA node SA node AV node Crista terminalis Orifice of coronary sinus AV bundle Orifice of coronary sinus Right bundle branch Left bundle branch Interventricular septum Location of AV node 40 41 This diagram shows the cardiac nerves and the locations of the superficial (a) and deep (b) cardiac plexuses. Vagal branches are shown as dashed lines and sympathetic branches are shown as dotted lines. The thoracic cardiac nerves from the upper thoracic sympathetic trunks are not shown. (From Textbook of Anatomy by W. Henry Hollinshead) 42 Auscultation Sites for the 4 Heart Valves Actual locations of the 4 heart valves projected onto the anterior thoracic wall. The actual locations do not correspond to the sites of auscultation. The sites of auscultation are where the chamber distal (in terms of blood flow) to the valve lies closest to the body surface. P=Pulmonary valve, A=Aortic valve, M=Mitral valve, and T=Tricuspid valve. (From Textbook of Anatomy by W. Henry Hollinshead) 43